Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Department of Surgery, Rijnstate, Arnhem, The Netherlands.
J Vasc Surg. 2019 Feb;69(2):348-356. doi: 10.1016/j.jvs.2018.05.218. Epub 2018 Aug 10.
The objective of this study was to investigate the feasibility of a specific custom-made fenestrated aortic cuff in the treatment of complex abdominal aortic aneurysms (AAAs).
Between 2013 and 2016, a total of 57 custom-made Fenestrated Anaconda (Vascutek, Inchinnan, Scotland, UK) aortic cuffs were placed in 38 centers worldwide. All centers were invited to participate in this retrospective analysis. Postoperative and follow-up data included the presence of adverse events, necessity for reintervention, and renal function.
Fifteen clinics participated, leading to 29 cases. Median age at operation was 74 years (interquartile range [IQR], 71-78 years); five patients were female. Two patients were treated for a para-anastomotic AAA after open AAA repair, 19 patients were treated because of a complicated course after primary endovascular AAA repair, and 8 cases were primary procedures for AAA. A total of 76 fenestrations (mean, 2.6 per case) were used. Four patients needed seven adjunctive procedures. Two patients underwent conversion, one because of a dissection of the superior mesenteric artery and one because of perforation of a renal artery. Median operation time was 225 minutes (IQR, 150-260 minutes); median blood loss, 200 mL (IQR, 100-500 mL); and median contrast volume, 150 mL (IQR, 92-260 mL). Primary technical success was achieved in 86% and secondary technical success in 93%. The 30-day morbidity was 7 of 29 with a mortality rate of 4 of 29. Estimated glomerular filtration rate remained unchanged before and after surgery (76 to 77 mL/min/m). Between preoperative and median follow-up of 11 months, estimated glomerular filtration rate was reduced statistically significantly (76 to 63 mL/min/m). During follow-up, 9 cases had an increase in aneurysm sac diameter (5 cases >5 mm); 14 cases had a stable or decreased aneurysm sac diameter; and in 2 cases, no aneurysm size was reported. No type I endoleak was reported, and two cases with a type III endoleak were treated by endovascular means during follow-up. Survival, reintervention-free survival, and target vessel patency at 1 year were 81% ± 8%, 75% ± 9%, and 99% ± 1%, respectively. After 2 years, these numbers were 81% ± 8%, 67% ± 11%, and 88% ± 6%, respectively. During follow-up, the two patients with a type III endoleak needed endograft-related reinterventions.
Treatment with this specific custom-made fenestrated aortic cuff is feasible after complicated previous (endovascular) aortic repair or in complex AAAs. The complexity of certain AAA cases is underlined in this study, and the Fenestrated Anaconda aortic cuff is a valid option in selected cases in which few treatment options are left.
本研究旨在探讨特定定制开窗主动脉袖套在治疗复杂型腹主动脉瘤（AAA）中的可行性。
2013 年至 2016 年，全球 38 个中心共放置了 57 个定制的 Fenestrated Anaconda（Vascutek，Inchinnan，苏格兰，英国）主动脉袖套。所有中心均被邀请参与这项回顾性分析。术后和随访数据包括不良事件的发生、再次干预的必要性以及肾功能。
15 家诊所参与了研究，共纳入 29 例患者。手术时的中位年龄为 74 岁（四分位距 [IQR]，71-78 岁）；5 例为女性。2 例患者因开放 AAA 修复后的吻合口旁 AAA 而接受治疗，19 例患者因初次血管内 AAA 修复后出现复杂病程而接受治疗，8 例为初次 AAA 治疗。共使用了 76 个开窗（平均每个病例 2.6 个）。4 例患者需要 7 种辅助手术。2 例患者需要转换，1 例因肠系膜上动脉夹层，1 例因肾动脉穿孔。中位手术时间为 225 分钟（IQR，150-260 分钟）；中位出血量为 200 毫升（IQR，100-500 毫升）；中位造影剂用量为 150 毫升（IQR，92-260 毫升）。主要技术成功率为 86%，次要技术成功率为 93%。30 天发病率为 29 例中的 7 例，死亡率为 29 例中的 4 例。手术前后肾小球滤过率保持不变（76 至 77 ml/min/m）。在中位随访 11 个月期间，肾小球滤过率显著降低（76 至 63 ml/min/m）。在随访期间，9 例患者的动脉瘤囊直径增大（5 例大于 5mm）；14 例患者的动脉瘤囊直径稳定或减小；2 例患者未报告动脉瘤大小。未报告 I 型内漏，2 例 III 型内漏在随访期间通过血管内治疗。1 年时的生存率、无再次干预生存率和靶血管通畅率分别为 81%±8%、75%±9%和 99%±1%。2 年后，这些数字分别为 81%±8%、67%±11%和 88%±6%。在随访期间，2 例 III 型内漏患者需要进行与移植物相关的再次干预。
在复杂的先前（血管内）主动脉修复或复杂的 AAA 后，使用这种特定的定制开窗主动脉袖套进行治疗是可行的。本研究突出了某些 AAA 病例的复杂性，在选择病例中， Fenestrated Anaconda 主动脉袖套是少数治疗选择之一。
